OCD-Related & Impulse-Control Disorders
Can't discard, can't stop pulling, can't resist the urge
Hoarding disorder
Core features. Hoarding disorder is persistent difficulty discarding possessions regardless of their value, driven by a perceived need to save them and distress at parting with them. The resulting clutter congests living areas until rooms cannot be used as intended. Most patients also acquire excessively, insight is often poor, and severity increases with age. Unlike collectors, who keep items organized and displayed, people who hoard live with clutter that causes distress or impairment.
Risks and treatment. Blocked exits and stacked belongings raise the risk of fire, falls, unsanitary conditions, and eviction, particularly in older adults living alone. The treatment of choice is hoarding-specific CBT: motivational work, sorting and decision-making skills, graded practice at discarding, and curbing acquisition, often delivered in the home. Forced clean-outs are traumatic and followed by rapid re-accumulation, although imminent safety hazards still require action. Rule out OCD (saving driven by typical obsessions), frontotemporal and other dementias, and psychosis.
Body-focused repetitive behaviors
Trichotillomania. Recurrent hair pulling produces hair loss despite repeated attempts to stop and causes distress. Irregular patches on the scalp, eyebrows, or eyelashes contain broken hairs of varying lengths, and the scalp shows no scale or inflammation. Pulling may be automatic (while reading or watching TV) or focused on relieving an urge. Unlike a tic, a brief stereotyped movement that relieves a premonitory urge, pulling is goal-directed and often soothing, sometimes followed by rituals such as inspecting or biting the root. Swallowing hair (trichophagia) can form a gastric trichobezoar, presenting with early satiety, vomiting, and an epigastric mass.
| Feature | Trichotillomania | Alopecia areata | Tinea capitis |
|---|---|---|---|
| Patch | Irregular, odd-shaped | Smooth, round, well-demarcated | Scaly, may be inflamed |
| Hairs | Broken, varying lengths | Exclamation-point hairs | Black dots (hairs broken at the scalp) |
| Other clues | Denial or secrecy; possible trichobezoar | Nail pitting; autoimmune disease | Posterior cervical nodes; boggy kerion |
| Treatment | Habit reversal training | Intralesional corticosteroids | Oral griseofulvin or terbinafine after KOH/culture |
Excoriation disorder. Recurrent picking at normal skin, acne, or scabs, most often on the face, arms, and hands, causes lesions, infection, or scarring, with failed efforts to stop and marked distress. Exclude picking driven by stimulant-induced formication, scabies or other skin disease, body dysmorphic disorder (picking to correct a perceived flaw), and delusions of infestation.
Delusional parasitosis. A fixed belief of skin infestation persists despite negative scrapings and repeated reassurance. Patients excoriate themselves and bring "specimens" of lint, skin, or debris in bags or boxes (the matchbox sign). Once true infestation, stimulant use, and medical causes are excluded, primary cases are delusional disorder, somatic type, treated with an antipsychotic such as risperidone or olanzapine within a trusting relationship rather than by arguing about the bugs. Repeated antiparasitic treatment reinforces the belief.
Treatment of pulling and picking. Habit reversal training (awareness training, a competing response, and social support) is first-line. N-acetylcysteine, a glutamate modulator, is a well-tolerated adjunct with placebo-controlled support in adult trichotillomania, and SSRIs or clomipramine are used, especially with comorbid anxiety or depression.
Impulse-control disorders
These disorders share an irresistible urge, rising tension before the act, and relief or gratification during it.
| Feature | Intermittent explosive disorder | Kleptomania | Pyromania |
|---|---|---|---|
| Core act | Impulsive verbal or physical outbursts far out of proportion to the trigger | Stealing objects not needed for use or value | Deliberate fire setting on more than one occasion |
| Pattern | Verbal aggression about twice weekly for 3 months, or 3 damaging or injurious outbursts in a year; usually under 30 minutes; age ≥6 | Tension before, relief during; items hoarded, given away, or returned | Arousal before; fascination with fire and its paraphernalia; relief watching |
| Afterward | Remorse or embarrassment | Guilt | Pleasure or relief |
| Treatment | CBT (anger management), SSRIs such as fluoxetine | CBT; naltrexone has some evidence | CBT |
What they are not. IED outbursts are unplanned and not aimed at a goal, unlike the instrumental, remorseless aggression of antisocial personality disorder; DMDD requires persistent irritability between outbursts with onset before 10. Kleptomania is not theft for gain, anger, or revenge. Pyromania is excluded when fires serve money, revenge, politics, or crime concealment, or reflect delusions, intoxication, dementia, conduct disorder, antisocial personality disorder, or mania. Primary pyromania is rare; most fire setting occurs with conduct disorder, ADHD, or other conditions.
Gambling disorder
Diagnosis. At least 4 of 9 features in 12 months: needing larger bets for the same excitement, restlessness when cutting back, repeated failed attempts to stop, preoccupation, gambling when distressed, chasing losses, lying to conceal gambling, jeopardizing relationships or jobs, and relying on others for bailouts. It is the only behavioral addiction grouped with substance-related and addictive disorders in DSM-5. Comorbid substance use and depression are common, and suicide risk is elevated.
Treatment. CBT, Gamblers Anonymous, and the opioid antagonist naltrexone.
Pramipexole and ropinirole, used for Parkinson disease and, less often now, restless legs syndrome (AASM 2024 advises against their standard use there), can trigger gambling, hypersexuality, compulsive shopping, and binge eating in a dose-related way, likely through mesolimbic D3 stimulation. Ask about these behaviors at every visit; the next step is tapering the agonist and relying more on levodopa. Aripiprazole carries a similar warning.